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Star of Life

In most circumstances in the United States, a paramedic is the most
advanced medical professional who typically responds to and treats
medical emergencies and trauma in the pre-hospital setting.
Paramedics normally provide assessment of illness and injuries,
including the gathering of medical history information, and provide
potentially life-sustaining medical treatment to the victim, both
on scene and during transportation to a hospital emergency
department. The training, supervision and licensing, and skill
sets for this group are determined at the State level, and vary
widely across the United States. Paramedics may be found in a
variety of settings, including traditional emergency medical
services (EMS),
other emergency services, such as both fire departments
and police, inside of hospitals and in industrial settings. The
position normally involves paid employment, although in
increasingly rare situations, one may find paramedics working as
unpaid volunteers.

History

Prior to 1970, ambulances were staffed with advanced first-aid level responders who were
frequently referred to as "ambulance drivers." There was little
regulation or standardized training for those staffing these early
emergency response vehicles. Around 1966 in a published report
entitled "Accidental Death and Disability: The Neglected Disease of
Modern Society",[1] (known
in EMS trade as the White Paper) medical researchers began to
reveal, to their astonishment, that soldiers who were seriously
wounded on the battlefields of Vietnam had a better survival rate than those
individuals who were seriously injured in motor vehicle accidents
on California
freeways. Early research attributed these differences in outcome to
a number of factors, including comprehensive trauma care,
rapid transport to designated trauma facilities, and a new type of
medical corpsman; one who was trained to
perform certain critical advanced medical procedures such as fluid
replacement and airway management, which allowed the
victim to survive the journey to definitive care.

As a result of this publication, a series of grand experiments
began in the United States. Pittsburgh's Freedom House paramedics are credited as
the first EMT trainees in America.
Pittsburgh's Peter
Safar is referred to as the father of CPR.[2] In
1967, he began training unemployed African-American
men in what later became Freedom House Ambulance Service,[3] the
first paramedic squadron in the United States.[4][5] Almost
simultaneously, and completely independent from one another,
experimental programs began in three U.S. centers; Miami, Florida,
Seattle, Washington, and Los Angeles, California. Each was aimed at
determining the effectiveness of using firefighters to perform many
of these same advanced medical skills in the pre-hospital setting
in the civilian world. Many in the senior administration of the
fire departments were initially quite opposed to this concept of
'firemen giving needles', and actively resisted and attempted to
cancel pilot programs more than once. In Seattle, the Medic
One program at Harborview Medical Center and
the University of Washington
Medical Center, started by Leonard Cobb, M.D., began training
firefighters in CPR in 1970.[6] Dr.
Eugene Nagel[7] trained
city of Miami firefighters as the first U.S. paramedics to use
invasive techniques and portable defibrillators with telemetry in
1967. In Los Angeles, a pilot paramedic program, involving
firefighters from only two county fire department rescue squads
initially, began under the direction of Ronald Stewart, M.D.[8]

Elsewhere, the novel approach to pre-hospital care was also
evolving. Portland's Leonard Rose, M.D., in cooperation with Buck
Ambulance Service, instituted a cardiac training program and began
training other paramedics. Baltimore's R. Adams Cowley,[9] the
father of trauma medicine, devised the concept of integrated
emergency care, designing the first civilian Medevac helicopter program
and campaigning for a statewide EMS system. Other communities that
were early participants in the development of paramedicine included
Jacksonville, Florida, Pittsburgh, Pennsylvania (in an expanded
program), and Seattle,
Washington (in an expanded program). In 1972 the first civilian
emergency medical helicopter transport service, Flight for Life
opened in Denver, Colorado.[10]
Emergency medical helicopters were soon put into service
elsewhere in the United States. It is now routine to have paramedic
and nurse-staffed EMS helicopters in most major metropolitan areas.
The vast majority of these aeromedical services are utilized for critical care air transport
(inter-hospital) in addition to emergency medical services
(pre-hospital).

In a curious example of 'life imitating art' a television
producer, working for producer Jack Webb,[11] of Dragnet
(series) and Adam-12
fame, happened to be in Los Angeles' UCLA Harbor Medical Center,
doing background research for a proposed new TV show about doctors,
when he happened to encounter these 'firemen who spoke like doctors
and worked with them'. This novel idea would eventually evolve into
the Emergency!
television series, which ran from 1972-1977, portraying the
exploits of a new group called 'paramedics'. The show captured the
imagination of emergency services personnel, the medical community,
and the general public. When the show first aired in 1972, there
were exactly 6 full-fledged paramedic units operating in 3 pilot
programs (Miami, Los Angeles, Seattle) in the whole of the United
States. No one had ever heard the term 'paramedic'; indeed, it is
reported that one of the show's actors was initially concerned that
the 'para' part of the term might involve jumping out of airplanes!
By the time the program ended production in 1977, there were
paramedics operating in every state. The show's technical advisor
was a pioneer of paramedicine, James O. Page,[12] then
a Battalion Chief responsible for the Los Angeles County Fire
Department 'paramedic' program, but who would go on to help
establish other paramedic programs in the U.S., and to become the
founding publisher of the Journal of Emergency
Medical Services.[13]

Throughout the 1970s and 80s, the field continued to evolve,
although in large measure, on a local level. In the broader scheme
of things the term 'ambulance service' was replaced by 'emergency
medical service' in order to reflect the change from a
transportation system to a system which provided actual medical
care. The training, knowledge base, and skill sets of both
paramedics and emergency medical technicians (both competed for the
job title, and 'EMT-Paramedic' was a common compromise) were
typically determined by what local medical directors were
comfortable with, what it was felt that the community needed, and
what could actually be afforded. There were also tremendous local
differences in the amount and type of training required, and how it
would be provided. This ranged from in-service training in local
systems, through community
colleges, and ultimately even to universities. During
the evolution of paramedicine, a great deal of both curriculum and
skill set was in a state of constant flux. Permissible skills
evolved in many cases at the local level, and were based upon the
preferences of physician advisers and medical directors. Treatments
would go in and out of fashion, and sometimes, back in again. The
use of certain drugs, Bretyllium for example, illustrate this. In
some respects, the development seemed almost faddish. Technologies
also evolved and changed, and as medical equipment manufacturers
quickly learned, the pre-hospital environment was not the same as
the hospital environment; equipment standards which worked fine in
hospitals could not cope well with the less controlled pre-hospital
environment.

Physicians began to take more interest in paramedics from a
research perspective as well. By about 1990, most of the
'trendiness' in pre-hospital emergency care had begun to disappear,
and was replaced by outcome-based research and evidence-based medicine;[14] the
gold standard for the rest of medicine. This research began to
drive the evolution of the practice of both paramedics and the
emergency physicians who oversaw their work; changes to procedures
and protocols began to occur only after significant outcome-based
research demonstrated their need. Paramedics became increasingly
accountable for their errors as well, and these too led to changes
in procedure.[15] Such
changes affected everything from simple procedures, such as CPR, to
changes in drug protocols and other advanced procedures.[16] As
the profession of paramedic grew, some of its members actually went
on to become not just research participants, but researchers in
their own right, with their own projects and journal
publications.

American paramedics at work

In the E/R

Managing a trauma patient

Bicycle paramedics, Los Angeles, California

On the streets of New York

Education

The education and skills required of paramedics vary by state.
The NHTSA
designs and specifies a National Standard Curriculum[17] for
EMT training. Most paramedic education and certifying programs
require that a student is at a minimum educated and trained to the
National Standard Curriculum for a particular skill level.[18] The
National Registry of Emergency Medical Technicians (NREMT) is a
private, central certifying entity whose primary purpose is to
maintain a national standard. NREMT also provides certification
information for paramedics who relocate to another state.[19]

Paramedic education programs can be as short as 8 months or as
long as 4 years. An Associate's degree program is 2 years, often
administered through a community college. Degree programs are an
option, with two year Associate's degree programs being most
common, although four year Bachelor's degree programs exist. The
institutions offering such training vary greatly across the country
in terms of programs and requirements, and each must be examined by
the prospective student in terms of both content and requirements
where the prospective paramedic hopes to practice.[20]
Regardless of education, all students must meet the same state
requirements to take the certification exams, including the
National Registry exams. In addition, most locales require that
paramedics attend ongoing refresher courses to maintain their
license or certification. In addition to state and national
registry certifications, most paramedics are required to be
certified in Pediatric Advanced Life Support, Pediatric Prehospital
care or Pediatric Emergencies for the Prehospital Provider;
Prehospital Trauma Life Support; International Trauma Life Support;
and Advanced Cardiac Life Support. These additional requirements
have education and certification from organizations such as the American Heart
Association.

Credentialling and
oversight

In the U.S., the community college training model remains the
most common, although university-based paramedic education models
continue to evolve. These variations in both educational approaches
and standards led to tremendous differences from one location to
another, and at its worst, created a situation in which a group of
people with 120 hours of training, and another group (in another
jurisdiction) with university degrees, were both calling themselves
'paramedics'. There were some efforts made to resolve these
discrepancies. The National Association of Emergency Medical
Technicians (NAEMT) along with National Registry of Emergency
Medical Technicians (NREMT)[21]
attempted to create a national standard by means of a common licensing examination, but to this day,
this has never been universally accepted by U.S. States, and issues
of licensing reciprocity for paramedics continue, although if a EMT
obtains certification through NREMT (NREMT-P, NREMT-I, NREMT-B),
this is accepted by 40 of the 50 states in the United States.[22] This
confusion was further complicated by the introduction of complex
systems of gradation of certification, reflecting levels of
training and skill, but these too were, for the most part, purely
local. To clarify, at least at a national level, the National
Highway Traffic Safety Administration (NHTSA), which is the
federal organization with authority to administer the EMS system,
defines the various titles given to prehospital medical workers
based on the level of care they provide. They are EMT-P
(Paramedic), EMT-I (Intermediate), EMT-B (Basic), and First
Responders. While providers at all levels are considered emergency
medical technicians, the term "paramedic" is most properly used in
the United States to refer only to those providers who are EMT-P's.
Apart from this distinction, the only truly common trend that would
evolve was the relatively universal acceptance of the term
'emergency medical technician' being used to denote a lower level
of training and skill than a 'paramedic'.

Changes in procedures also included the manner in which the work
of paramedics was overseen and managed. In the earliest days of the
field, medical control and oversight was direct and immediate, with
paramedics calling into a local hospital and receiving orders for
every individual procedure or drug.[23] This
still occurs in some jurisdictions, but is becoming very rare. As
physicians began to build a bond of trust with paramedics, and
experience in working with them, their confidence levels also rose.
Increasingly, in many jurisdictions day to day operations moved
from direct and immediate medical control to pre-written protocols
or 'standing orders', with the paramedic typically only calling in
for direction after the options in the standing orders had been
exhausted.[24]
Medical oversight became driven more by chart review or rounds,
than by step by step control during each call.

Examples of skills
performed by paramedics

Just as with the use of medications, the other medical skills
and procedures permitted to paramedics varies broadly from one
jurisdiction to another. It is not possible to provide a single set
of skills or medications which would be universally representative
of all paramedics in the United States. The lists which follow,
while not universal, are fairly representative.

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Skills by certification
level

Although there is a great deal of variation in what paramedics
are trained and permitted to do from region to region, some skills
performed by paramedics include:

Assessment of pulse (rate, rhythm, volume), blood pressure
and capillary refill, patient positioning to enhance circulation,
recognition and control of hemorrhage of all types using direct and
indirect pressure and tourniquets

Dramatically expanded (up to 60+) drug list. In some
jurisdictions advanced levels of paramedics are permitted to
administer any drug, as long as they are familiar with it. In some
jurisdictions certain types of advanced paramedics have limited
authority to prescribe medications.

Patient assessment

Basic physical assessment, 'vital' signs, history of general
and current condition

Medications administered

Paramedics in most jurisdictions administer a variety of
emergency medications; the individual medications
vary widely, based on physician medical director preference, local
standard of care, and law. These drugs may include Adenocard
(Adenosine),[28] which
will slow the heart for a short period of time, and Atropine, which
will speed a heartbeat that is too slow. The list may include sympathomimetics like dopamine for severe hypotension (low blood pressure) and
cardiogenic shock. Diabetics often benefit from the fact that
paramedics are able to give D50W (Dextrose 50%) to treat
hypoglycemia (low blood sugar). They can treat crisis and anxiety
conditions. Some advanced paramedics may also be permitted to
perform rapid sequence induction; a rapid way of obtaining an
advanced airway with the use of paralytics and sedatives, using
such medications as Versed, Ativan, or Etomidate, and paralytics such as succinylcholine, rocuronium, or vecuronium.[29]
Paramedics in some jurisdictions may also be permitted to sedate
combative patients using antipsychotics like Haldol or Geodon.[30] The
use of medications for treating respiratory conditions such as, albuterol, atrovent, and methylprednisolone is common.
Paramedics may also be permitted to administer medications such as
those which relieve pain or decrease nausea and vomiting. Nitroglycerin, baby
aspirin, and morphine sulfate
may be administered for chest pain. Paramedics may also use other
medications and antiarrhythmics like amiodarone to treat cardiac arrhythmias such as ventricular tachycardia and ventricular fibrillation not
responding to defibrillation.[31]
Paramedics also treat for severe pain, i.e. burns or fractures,
with narcotics like morphine sulfate,
pethidine, fentanyl and in some
jurisdictions, ketorolac. This list is not representative of
all jurisdictions, and EMS jurisdictions may vary greatly in what
is permitted. Some jurisdictions may not permit administration of
certain classes of drugs, or may use drugs other than the ones
listed for the same purposes. For an accurate description of
permitted drugs or procedures in a given location, it is necessary
to contact that jurisdiction directly.

Employment

Paramedics are employed by various public and private emergency
service providers. These include private ambulance services,
fire departments, public safety or police departments, hospitals,
law enforcement agencies, the military, and municipal EMS agencies
in addition to and independent from police or fire departments,
also known as a 'third service'. Paramedics may respond to medical
incidents in an ambulance, rescue vehicle, helicopter,
fixed-wing aircraft, motorcycle, or fire suppression apparatus.

Example of an official shoulder emblem worn by paramedics to
identify their advanced level of care.

Paramedics may also be employed in medical fields that do not
involve transportation of patients. Such positions include offshore
drilling platforms, phlebotomy, blood banks, research labs, educational
fields, law enforcement and hospitals.[32]

Aside from their traditional roles, paramedics may also
participate in one of many specialty arenas:

Critical care transporters move patients by
ground ambulance or aircraft between medical treatment
facilies. This may be done to allow a patient to receive a
higher level of care in a more specialized facility. Registered
Nurses with training in critical care
medicine may work side-by-side with paramedics in these
settings. Paramedics participating in this role generally also
provide care not traditionally administered by Paramedics who
respond to 911 calls. Examples of this are blood transfusions, intra-aortic balloon pumps,
and mechanical ventilators.[33]

Tactical paramedics work on law enforcement
teams (SWAT). These medics,
usually from the EMS agency in the area, are commissioned and
trained to be tactical operators in law enforcement, in addition to
paramedic duties. Advanced medical personnel perform dual roles as
operator and medic on the teams. Such an officer is immediately
available to deliver advanced emergency care to other injured
officers, suspects, innocent victims and bystanders.[34]

In-Hospital paramedics are increasingly
employed in hospital emergency departments and intensive care units due to the nursing
shortage. In emergent situations, paramedics are generally
accustomed to practicing with greater latitude and autonomy than registered
nurses due to their specialized training, which emphasizes
discretionary decisions and treatment without mandatory physician
consultation.[35]

See also

References

^National Research Council; Committee on
Trauma and Committee on Shock; Division of Medical Sciences;
National Academy of Sciences (2000). Accidental Death and
Disability: The Neglected Disease of Modern Society.
Washington, D.C: National Academies Press. ISBN
0-309-07532-7.

EMS: Coping with the Unthinkable - EMS: Courage and Compassion in Action: Coping with the Unthinkable - / iBerkshires.com - The Berkshires online guide to events, news and Berkshire County community information.